Influence of Artificial Tears on Keratometric
Measurements in Cataract Patients
VERONIKA RÖGGLA, CHRISTINA LEYDOLT, DANIEL SCHARTMÜLLER, LUCA SCHWARZENBACHER,
ELIAS MEYER, CLAUDETTE ABELA-FORMANEK, AND RUPERT MENAPACE

PURPOSE: To assess the influence of artificial tears of
different viscosity on K-readings prior to cataract surgery.

DESIGN: Prospective randomized crossover, before-
and-after clinical study.

METHODS: SETTING: Department of Ophthalmology,
Medical University of Vienna. PATIENT POPULATION: A
total of 123 eyes of 80 patients prior to cataract surgery
were assigned to 2 groups based on normal and dry eyes.
INTERVENTION: Two native baseline keratometries were
followed by instillation of either high- or low-viscosity
eye drops. Keratometry was repeated 30 seconds, 2 mi-
nutes, and 5 minutes after instillation. MAIN OUTCOME
MEASURES: Influence of eye drops of different viscosity
in normal and dry eyes on short time K-readings.

RESULTS: Repeatability between native baseline mea-
surements was high (standard deviation [ 0.02 mm in
normal and in dry eyes). In normal and dry eyes, a statis-
tically significant increase in measurement variability af-
ter instillation of both low-viscosity and high-viscosity
eye drops was observed (P < .01). Measurement vari-
ability was most pronounced between baseline measure-
ment and 30 seconds and diminished over time.
Variability of K-readings appeared higher in dry eyes
compared with normal eyes. Astigmatism changed more
than 0.5 diopters in 13.2% of normal eyes and 34.4%
in dry eyes using eye drops of high viscosity.

CONCLUSION: Tear film–stabilizing eye drops prior to
keratometry measurements influenced K-readings signif-
icantly, especially in dry eyes. A time period of more
than 5 minutes should be allowed to pass after instillation
of eye drops. The higher the viscosity of the eye drops, the
stronger the influence and the longer its
persistence. (Am J Ophthalmol 2021;221:1–8. Ó
2020 The Author(s). Published by Elsevier Inc. This is
an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.
0/).)
Accepted for publication Aug 12, 2020.
From the Department of Ophthalmology and Optometry (V.R., C.L.,
D.S., L.S., C.A.-F., R.M.) and Section for Medical Statistics, Center for
Medical Statistics, Informatics and Intelligent Systems (E.M.), Medical
University of Vienna, Vienna, Austria.
Inquiries to Rupert Menapace, Department of Ophthalmology and
Optometry, Medical University of Vienna, Spitalgasse 23, 1090 Vienna,
Austria; e-mail: rupert.menapace@meduniwien.ac.at
0002-9394 © 2020 THE AUTHOR(S). PUBLISHED
https://doi.org/10.1016/j.ajo.2020.08.024
T
HE DEVELOPMENTS OF ADVANCED-TECHNOLOGY
intraocular lenses (IOLs) and new measuring de-
vices have heightened expectations of visual
outcome after cataract surgery. In a recent study, refractive
errors greater than 60.5 diopter (D) were reported in
approximately 20% to 40% of all cases.1–5 Proper IOL
power selection is crucial for a good uncorrected visual
outcome. Keratometry is a key component of biometry
for IOL power calculations. The IOL Master 500 reflects
6 peripheral measurement points, arranged hexagonally
on an approximately 2.5 mm radius on the central
corneal surface, or rather on the tear film.6,7 Digital calipers
measure the separation of the opposite measuring points to
obtain keratometry readings. The mean of the 3 fixed me-
ridians is used to calculate the corneal power. Therefore, a
stable tear film must be provided for an accurate and repro-
ducible keratometry.
Dry-eye disease is multifactorial and causes an unsta-
ble tear film with an irregular surface. Symptoms include
a burning sensation and blurred vision, and bio-
microscopic signs like shortened tear breakup time,
corneal and conjunctival fluorescein staining, and lid-
parallel conjunctival folds. The disease prevalence
ranges from approximately 5% to 50%.8 Given that
the prevalence increases with age, it is a common
concern for patients in need of cataract surgery. The
ocular surface is irregular and can change markedly
within every blink. Disruption of the tear film results
in additional aberrations, leading to unreliable keratom-
etry measurements in dry eyes.9
In a clinical setting, the biometry sometimes has to be
repeated several times because of an unstable tear film.
Both short- and long-term repeatability of keratometry of
dry eyes are known for their high variability.9 Artificial
tears are often used to ameliorate the ocular surface for
obtaining a precise measurement of the eye. However,
there are anecdotal reports that usage of eye drops can alter
the measurement.9,10 To our knowledge, this has not been
empirically tested in a pertinent clinical study. Also, there
is no recommendation on whether or not artificial tears
should be used to produce a regular tear film or if used,
the appropriate interval that should be left after instillation
of eye drops.
In this study, changes in keratometry measurements due
to the influence of eye drops with different viscosities were
investigated.
BY ELSEVIER INC. 1
 METHODS
THIS PROSPECTIVE, RANDOMIZED STUDY WAS CONDUCTED
at the Medical University of Vienna. A total of 80 patients
with 40 patients in each subgroup was involved in the study.
They were divided into 2 groups of 40 patients each: Pa-
tients with normal eyes, without dry-eye syndrome, were
allocated to Group N, and those with mild to moderate
dry-eye syndrome to Group D. According to the Dry Eye
Workshop 2017, we diagnosed dry eyes as tear breakup
time less than 10 seconds or the presence of punctuated
keratitis with corneal staining.8 Institutional ethics approval
was obtained before the initiation of the study and adhered
to the tenets of the Declaration of Helsinki. The study was
registered at ClinicalTrials.gov (NCT04196621). Written
informed consent was received from all patients.
Exclusion criteria were any corneal pathology, the use of
any eye drops 24 hours before the examination, a necessity
for any topical eye therapy, active ocular or nasal allergies,
corneal or conjunctival infection, abnormalities of the
nasolacrimal drainage apparatus, level 4 dry-eye severity,
eyelid deformities, and preceding ocular surgery or trauma.
At study visit 1, patients were included and assigned to
the normal or dry-eye group. If only one eye was included,
the eye drops to be used at study visit 2 were assigned
randomly. At study visit 3, the other of the 2 different types
of eye drops was instilled.
Both at study visit 2 and 3, keratometry was performed 5
times: 2 times each before the application of eye drops and
then 30 seconds, 2 minutes and 5 minutes after the applica-
tion of eye drops. The IOL Master 500 (Carl Zeiss Meditec
AG, Jena, Germany) was used for all measurements. The pa-
tients were instructed to blink a few times immediately before
each measurement. The first and second measurements were
performed consecutively, with only a few seconds in between
the measurements. Subsequently, the assigned eye drops were
instilled, and the measurements were repeated 30 seconds,
2 minutes, and 5 minutes after instillation.
To prevent diurnal changes, all examinations were
performed between 9 a.m. and 2 p.m. An interval of at least
24 hours was maintained between each visit.
If both eyes were included, the study eye and type of eye
drops for study visit 2 were chosen randomly. The order of
the eye drops was inverted for the other eye and used for the
secondary objectives detailed below.
Data were analyzed in following groups:
N1: Instillation of high-viscosity eye drops in normal
eyes
N2: Instillation of low-viscosity eye drops in normal eyes
D1: Instillation of high-viscosity eye drops in dry eyes
D2: Instillation of low-viscosity eye drops in dry eyes

STATISTICAL ANALYSIS: Appropriate descriptive statis-
tics (the mean and SD for continuous and absolute and
2 AMERICAN JOURNAL OF OPHTHALMOLOGY
relative frequencies for categorical variables) were
computed.
For the primary objective, only one eye per patient was
used. For the exploratory secondary objectives, all
measured eyes were used.
The primary objective was to determine whether
applying high-viscosity eye drops in normal eyes leads to
a change in k-values after 30 seconds. A change in the k-
value was defined as either a mean difference between mea-
surements before and 30 seconds after applying eye drops
that is significantly different from zero or an increased SD
of differences in measurements before and 30 seconds after
applying eye drops compared with differences between the
2 measurements before the application of eye drops.
Two tests were conducted at significance level <.05/2 ¼
.025 for the analysis of the primary objective because kera-
tometry measurements may increase or decrease after eye
drops are applied.
First, a 1-sample t test was used to assess whether the
mean difference between the second keratometry measure-
ments before and the keratometry measurement 30 seconds
after application of eye drops is significantly different from
zero.
Second, 2 linear mixed models were used to test whether
the SD of differences between keratometry measurements
before and 30 seconds after applying eye drops is different
from the SD of differences between the 2 k-value measure-
ments prior to the application of eye drops. For both
models, the dependent variable was the k-value measure-
ment and the fixed effect was the categorical variable
time (the first initial measurement, second initial measure-
ment, and 30 seconds after applying eye drops). The first
linear mixed model (M1) included a random intercept
per patient and a time-additive random slope per patient
(independent of the random intercept). The second linear
mixed model (M2) included a random intercept per patient
and 2 different random slopes per patient, modeling the dif-
ference between the second and first initial measurement
and the difference between 30 seconds after eye drops
were applied and the second initial measurement separately
(the 2 random slopes were not independent, but both were
independent of the random intercept). A likelihood ratio
test was used to check whether the more complex model
M2 fitted the data significantly better.
If either of the 2 tests yielded a significant P value, the
hypothesis of ‘‘no change in the k value’’ was rejected at sig-
nificance level a ¼ 0.05.
The exploratory secondary objectives were to determine
whether applying either high- or low-viscosity eye drops in
either normal or dry eyes leads to a change in k values for all
the remaining time points. These objectives were assessed
analogously to the primary objective.
Because the decision for toric IOL implantation is
mainly based on the measurements of the anterior corneal
cylinder, the difference in astigmatism (in diopters)
measured with and without eye drops was compared. The
JANUARY 2021
 after applying eye drops was different from the SD of differ-
TABLE 1. Demographic Data ences of the 2 measurements before the application of eye
drops. For both, the clinically relevant change in the mean
Normal Eyes Dry Eyes
of 0.15 and the clinically relevant change in SD of 0.4, a
Age (y) 67.59 6 9.1 72.03 6 8.4 power of at least 80% was achieved when including 40 pa-
Sex, female/male 46.15%/53.85% 55.6%/44.4% tients with normal (and not dry) eyes, which led to a final
Right/left 45%/55% 48%/52% sample size of 80 patients.
Axial length (mm) 23.72 6 1.60 23.57 6 1.18
K (mm) 7.69 6 0.22 7.63 6 0.25
K (D)a 43.17 6 1.51 43.51 6 1.33
K 1 (mm) 7.77 6 0.21 7.7 6 0.25
K 1 (D)a 42.73 6 1.58 43.12 6 1.33 RESULTS
K 2 (mm) 7.62 6 0.21 7.55 6 0.27

DESCRIPTIVE ANALYSIS: Of the 80 patients included, 6
K 2 (D)a 43.57 6 1.58 43.97 6 1.23
patients were lost to follow-up, leaving a final sample size
D ¼ diopters. of 39 patients with normal and 35 patients with dry eyes.
Unless otherwise noted, values are mean 6 SD. The keratom- Data were collected from the normal- (69 eyes of 39 pa-
etry values are calculated from native measurements. tients) and dry-eye group (54 eyes of 35 patients). Each
a
k index: 1.332.
eye was measured twice, with each type of artificial tears
on a separate day. Demographic data are shown in Table 1.
Changes of 0.5-1.0 D of astigmatism were observed be-
percentage of eyes with a change of 0.5 and 1 D was tween the native measurements in 2.6% of normal eyes
calculated. and in 4.2% of dry eyes. The native measurements varied
To assess the repeatability of the native keratometry less than 1 D. Compared with the first native measurement,
measurements, SD of the differences between the first keratometric measurements varied by more than 0.5 D in
and second native baseline measurement of normal and 13.2% of the normal eyes when performed 30 seconds after
dry eyes was calculated separately. Only one eye per patient instillation of both high (group N1) and low-viscosity eye
at study visit 2 was used for the SD calculation. drops (group N.2). In dry eyes (groups D1 and D2), these
Astigmatism was decomposed into X and Y vector com- changes of more than 0.5 D have been observed in 34.3%
ponents, with X ¼ |astigmatism_cylinder| 3 cos (2 3 and 27.8%, respectively. A difference of 1 D or higher
astigmatism_axis) and Y ¼ |astigmatism_cylinder| 3 sin was observed in 2.6% (groups N1 and N2), 2.7% (group
(2 3 astigmatism_axis). Differences between native and D2), and 8.6% (group D1). Considering all data, the
30 seconds, 2 minutes, and 5 minutes were derived by mean vector difference between the first and second native
subtracting the respective X and Y vector components. measurement was 0.27 6 0.20 D, between the first native
The difference vectors were extracted from the X and Y and the 30-second measurement was 0.52 6 0.40 D, be-
components by absolute value of the difference and orien- tween the first native and the 2-minute measurement was
tation. Components of the difference vector from native to 0.40 6 0.35 D, and between the first native and the 5-
30-second measurement were displayed in a double-angle minute measurement was 0.35 6 0.27 D. No differences be-
plot with dY_native_30 seconds plotted on the ordinate tween the subgroups were observed. In Figure 1, the
and dX_native_30 seconds plotted on the abscissa. changes between the first native measurement and 30 sec-
Statistical analyses were conducted using the free soft- onds after instillation of eye drops are shown.
ware environment R.

PRIMARY OBJECTIVE: With an observed mean of þ0.004

SAMPLE SIZE CALCULATION: Following Shajari and as- (95% CI 0.02, 0.03), the mean difference in keratometry
sociates,11 we assumed the differences in k values between measurements (both native measurements vs 30-second
the first and second measurement prior to the application of and second native measurements) was not significantly
eye drops was normally distributed with a mean ¼ 0 and different from zero (P ¼ .724). Using the likelihood ratio
SD ¼ 0.23. The null hypothesis was that the differences test as described in the Methods section, the more complex
in k values between the second measurement before model with eye drops as the influencing factor fitted the
applying eye drops and the one 30 seconds after the appli- data significantly better (x2 ¼ 33.13, df ¼ 2, P < .001).
cation of eye drops was also normally distributed, with a Figure 2 show the distribution of differences of k values.
mean ¼ 0 and SD ¼ 0.23. For each of a range of alternative
hypotheses on the mean and the SD, we simulated 5,000
SECONDARY OBJECTIVES: Similar to the primary objec-
trials and computed the proportion of trials that would tive, t-test results were not statistically significant in any
reject the null hypothesis. In this simulation, for reasons group. The means of the respective 95% confidence inter-
of simplicity, we used an F test to test whether the SD of vals and P values are listed in Table 2. With the exception
differences between measurements before and 30 seconds of group N2, the more complex model fitted the data

VOL. 221 KERATOMETRY AND INFLUENCING FACTORS 3

FIGURE 1. Double-angle plot of vector difference between corneal astigmatism from the first native keratometry and 30 seconds
after instillation of eye drops.

FIGURE 2. Distribution of differences in k values between the native measurements and those 30 seconds after instillation of highly
viscous eye drops. f [ first measurement, s [ second measurement, 30 sec [ 30 seconds after instillation of eye drops.

significantly better 30 seconds and 2 minutes after instilla-
tion, but did not fit the data significantly better after 5 mi-
nutes. In group N2, the more complex model fitted the data
better 30 seconds, 2 minutes, and 5 minutes after
instillation.
As it can be seen in Figure 3, the differences 30 seconds
after instillation deviate significantly and regress with time
but are still not within the normal distribution range after
2 minutes.
Figure 4 shows examples of individual patients’ keratom-
etry values in diopters over time. Both extreme increases
and extreme decreases can be observed.
The SD of the differences between the first and second
native baseline measurements was 0.02 mm each in normal
eyes and in dry eyes.
DISCUSSION
CATARACT SURGERY IS A SUCCESSFUL PROCEDURE FOR
restoring vision. The market is highly competitive,
providing highly accurate devices, intraocular lenses, and
promises of dispensability of glasses after surgery.

4 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 2021

 TABLE 2. Results of Means of Respective 95% Confidence Intervals and P Values of the t Test and Mixed Model

High-viscosity eye drops Normal Eyes Dry Eyes

30 seconds 0.0095 [0.0036; 0.0225], P ¼ .149 0.0040 [0.0188; 0.0268], P ¼ .724

Mean [95% CI], P value (t test) (x2 ¼ 19.78, df ¼ 2, P < .001) (x2 ¼ 33.13, df ¼ 2, P < .001)
Mixed model result
2 minutes 0.0021 [0.0083; 0.0126], P ¼. 686 0.0031 [–0.0218; 0.0155], P ¼ .734
Mean [95% CI], P value (t test) (x2 ¼ 10.25, df ¼ 2, P ¼ .006) (x2 ¼ 23.24, df ¼ 2, P < .001)
Mixed model result
5 minutes 0.0018 [0.0070; 0.0107], P ¼ .677 0.0006 [0.0122; 0.0111], P ¼ .921
Mean [95% CI], P value (t test) (x2 ¼ 4.67, df ¼ 2, P ¼ .097) (x2 ¼ 7.106, df ¼ 2, P ¼ .0286)
Mixed model result
Low-viscosity eye drops

30 seconds 0.0035 [0.0122; 0.0193], P ¼ .653 0.0103 [0.0075; 0.0280], P ¼ .248

Mean [95% CI], P value (t test) (x2 ¼ 39.25, df ¼ 2, P < .001) (x2 ¼ 38.50, df ¼ 2, P < .001)
Mixed model result
2 minutes 0.0108 [0.0022; 0.0001]; P ¼ .048 0.005 [0.0041; 0.0141]; P ¼ .274
Mean [95% CI], P value (t test) (x2 ¼ 19.70, df ¼ 2, P < .001) (x2 ¼ 7.48, df ¼ 2, P ¼ .024)
Mixed model result
5 minutes 0.0016 [0.0108; 0.0076]; P ¼ .722 0.0042 [0.0128; 0.0045]; P ¼ .333
Mean [95% CI], P value (t test) (x2 ¼ 11.30, df ¼ 2, P ¼ .004) (x2 ¼ 5.83, df ¼ 2, P ¼ .054)
Mixed model result

The table presents the results of the tests conducted to determine whether application of high-viscosity eye drops in normal eyes leads to a
change in k values after 30 seconds. For every time point, the first row shows the results of the 1-sample t test conducted to test whether the
mean difference of the second native measurements before and the measurement 30 seconds after application of eye drops is significantly
different from zero. The second row for every time point shows results of the mixed model, which was used to analyze a change in variation.

Therefore, a perfect interplay of preoperative examina-
tions, formula choices, and intraocular lens decisions is
required. This is particularly true for multifocal and
extended-depth-of-focus IOLs. However, in many cases,
basic steps such as performing a proper biometry seem to
be disregarded. Considering the importance of validated
measurements, focusing on accurate keratometry measure-
ments is crucial.12
We investigated the reproducibility of keratometry ob-
tained by the automated keratometer of an automated
biometry device in normal and dry eyes and the impact
of adding lubricants of different viscosities. Significant
changes in keratometry values after instillation of both
low- and high-viscosity eye drops were observed. Both
high- and low-viscosity eye drops were determined to be
powerful influencing factors. Five minutes after instillation,
however, differences were no longer statistically signifi-
cant, except in group N2, although still present. These re-
sults are in agreement with those of Koh and associates.13
Only few publications address the problem of dry eye syn-
drome and usage of eye drops before performing keratome-
try.10,14–16 Montes-Mico and associates demonstrated, in
agreement with our results, a significant change of total,
spherelike and commalike aberrations after the application
of artificial tears.11 In contrast to our results, this change
was still significant 5 and 10 minutes after instillation. The
eye drops used contained 0.18% sodium hyaluronate, which
is almost twice as much as that in our high-viscosity drops
(0.1%). This may explain the longer maintenance and as a
result statistically significant changes 10 minutes after instil-
lation. Our results show the differences were no longer statis-
tically significant 5 minutes after the use of eye drops.
Immediately after instillation of eye drops (30 seconds,
2 minutes), both the k-value and astigmatism showed
significantly increased variability in each group. Thirty sec-
onds after applying eye drops, measurements in 13% to
34% of all eyes differed more than 0.5 D from the native
measurements depending on the tear film quality and the
lubricant used to improve the tear film. The difference be-
tween normal and dry eyes is particularly interesting. As
expected, measurements of dry eyes seem to be even less
reliable than those of normal eyes. This is an important
aspect to consider because dry eyes especially are instilled
with artificial tears before keratometry.
Measurement variabilities were increased significantly
after instillation of eye drops, and those variabilities
decreased with time. Five minutes after applying the lubri-
cants used in our study, the variabilities were no longer sta-
tistically different, except in one group (N2). Still,
variabilities greater than those between native measure-
ments can be seen with each lubricant. Therefore, the in-
fluence of artificial tears seems to last approximately
5 minutes. Any biometry should be performed before instil-
lation of artificial tears or after 5 minutes.

VOL. 221 KERATOMETRY AND INFLUENCING FACTORS 5

FIGURE 3. Change in k value 30 seconds (A) and 2 minutes (B) after instillation of low-viscosity eye drops in dry eyes. The first
measurements were centered to emphasize the deviation. f [ first measurement, s [ second measurement, 30 sec [ 30 seconds after
instillation of eye drops, 2 min [ 2 minutes after instillation of eye drops.

Usage of artificial tears changes the k value as well as the
astigmatism measurements more in dry eyes than in normal
eyes. The impact of the viscosity of artificial tears used is
less than that of the corneal surface or tear film condition.
Many of the patients’ keratometry values did not vary
significantly. Nevertheless, the number of significant out-
liers was high, and incorrect measurements of 1 D of
corneal power lead to approximately 1-D error
postoperatively.17
Figure 4 shows examples of time courses in patients with
dry eye syndrome. Interestingly, instilled eyes did not
follow any trend, increasing or decreasing the diopters.
The results seemed to scatter randomly. More important
it is not to rely on measurements taken immediately after
the application of eye drops.
This study did not consider measurements later than 5 mi-
nutes after eye drop instillation. Therefore, a protracted in-
fluence can only be inferred. In several studies, differences
were significant after 5 minutes and longer.13,18 One limita-
tion is the lack of a comparison with eyes where no eye drops
were applied in the time frame of 5 minutes. As in other
studies, the patients were instructed to blink and close their
eyes in between measurements. Hence, the keratometry after
2 and 5 minutes can be compared with any study investi-
gating the repeatability of the IOL Master, showing high
repeatability.11,19 The study of Shajari and associates showed
a coefficient of repeatability of 0.093 and 0.084 for the
corneal curvature in the flat and steep meridian.11 Another
limitation is the missing separation of mild and moderate dry
eyes. As a change of 0.5 D was observed more often in dry
eyes than normal eyes, there might also be a bigger influence
in moderate dry eyes than in mild dry eyes. This study inves-
tigated the measurements with the IOL Master 500, and no
conclusions can be drawn for newer versions of IOL Master.
Further investigation is needed.
To conclude, instillation of any eye drops before
performing a keratometry during biometry should be
performed with great care. Either no eye drops should be
used or keratometry must be delayed for more than 5 mi-
nutes. This rule of thumb applies even more for dry eyes,
because their measurements presented higher scatter and
lower reproducibility and were, therefore, less reliable.
Furthermore, the higher the viscosity of eye drops, the
longer the influence on the ocular surface and therefore
the longer the interval required before measuring the
ocular surface.

6 AMERICAN JOURNAL OF OPHTHALMOLOGY JANUARY 2021

FIGURE 4. Examples of outliers with extreme changes in diopters in time (group D2) f [ first measurement, s [ second measure-
ment, 30 sec [ 30 seconds after instillation of eye drops, 2 min [ 2 minutes after instillation of eye drops, 5 min [ 5 minutes after
instillation of eye drops.

CRediT AUTHORSHIP CONTRIBUTION ing, Investigation, Project administration. Luca Schwar-

STATEMENT
VERONIKA RÖGGLA: CONCEPTUALIZATION, METHODOL-
ogy, Formal analysis, Writing - original draft, Writing - re-
view & editing, Investigation, Resources, Funding
acquisition, Project administration. Christina Leydolt:
Conceptualization, Methodology, Formal analysis, Writing
- original draft, Writing - review & editing, Investigation,
Resources, Project administration. Daniel Schartmüller:
Conceptualization, Methodology, Writing - review & edit-
zenbacher: Conceptualization, Methodology, Writing -
review & editing, Investigation, Project administration.
Elias Meyer: Conceptualization, Methodology, Formal
analysis, Writing - review & editing, Resources, Project
administration, Conceptualization, Methodology, Writing
- review & editing, Resources, Project administration.
Claudette Abela-Formanek: Conceptualization, Method-
ology, Formal analysis, Writing - original draft, Writing -
review & editing, Resources, Project administration.

FUNDING/SUPPORT: THIS STUDY RECEIVED NO FUNDING. FINANCIAL DISCLOSURES: THE AUTHORS INDICATE NO FINANCIAL
support or conflicts of interest. All authors attest that they meet the current ICMJE criteria for authorship.

REFERENCES with normal axial lengths. J Cataract Refract Surg 2018;

44(3):362–368.
1. Gökce SE, Montes De Oca I, Cooke DL, Wang L, Koch DD, 2. Kane JX, Van Heerden A, Atik A, Petsoglou C. Intraocular
Al-Mohtaseb Z. Accuracy of 8 intraocular lens calculation lens power formula accuracy: comparison of 7 formulas. J
formulas in relation to anterior chamber depth in patients Cataract Refract Surg 2016;42(10):1490–1500.

VOL. 221 KERATOMETRY AND INFLUENCING FACTORS 7

 3. Aristodemou P, Knox Cartwright NE, Sparrow JM,
Johnston RL. Formula choice: Hoffer Q, Holladay 1, or
SRK/T and refractive outcomes in 8108 eyes after cataract
surgery with biometry by partial coherence interferometry. J
Cataract Refract Surg 2011;37(1):63–71.
4. Melles RB, Holladay JT, Chang WJ. Accuracy of intraocular
lens calculation formulas. Ophthalmology 2018;125(2):
169–178.
5. Cooke DL, Cooke TL. Comparison of 9 intraocular lens po-
wer calculation formulas. J Cataract Refract Surg 2016;42(8):
1157–1164.
6. Shammas HJ, Chan S. Precision of biometry, keratometry,
and refractive measurements with a partial coherence
interferometry–keratometry device. J Cataract Refract Surg
2010;36(9):1474–1478.
7. Visser N, Berendschot TTJM, Verbakel F, De Brabander J,
Nuijts RMMA. Comparability and repeatability of corneal
astigmatism measurements using different measurement tech-
nologies. J Cataract Refract Surg 2012;38(10):1764–1770.
8. Stapleton F, Alves M, Bunya VY, et al. TFOS DEWS II epide-
miology report. Ocul Surf 2017;15(3):334–365.
9. Epitropoulos AT, Matossian C, Berdy GJ, Malhotra RP,
Potvin R. Effect of tear osmolarity on repeatability of kera-
tometry for cataract surgery planning. J Cataract Refract Surg
2015;41(8):1672–1677.
10. Montés-Micó R, Cáliz A, Alió JL. Changes in ocular aberra-
tions after instillation of artificial tears in dry-eye patients. J
Cataract Refract Surg 2004;30(8):1649–1652.
11. Shajari M, Cremonese C, Petermann K, Singh P, Müller M,
Kohnen T. Comparison of axial length, corneal curvature,
and anterior chamber depth measurements of 2 recently
8 AMERICAN JOURNAL OF OPHTHALMOLOGY
introduced devices to a known biometer. Am J Ophthalmol
2017;178:58–64.
12. Sheard R. Optimising biometry for best outcomes in cataract
surgery. Eye 2014;28(2):118–125.
13. Koh S, Maeda N, Ikeda C, et al. Effect of instillation of
eyedrops for dry eye on optical quality. Invest Ophthalmol
Vis Sci 2013;54(7):4927–4933.
14. Pavlopoulos GP, Horn J, Feldman ST. The effect of artificial
tears on computer-assisted corneal topography in normal eyes
and after penetrating keratoplasty. Am J Ophthalmol 1995;
119(6):712–722.
15. Hiraoka T, Daito M, Okamoto F, Kiuchi T, Oshika T. Time
course of changes in ocular aberrations after instillation of
carteolol long-acting solution and timolol gel-forming solu-
tion. J Ocul Pharmacol Ther 2011;27(2):179–185.
16. Lu N, Lin F, Huang Z, He Q, Han W. Changes of corneal
wavefront aberrations in dry eye patients after treatment
with artificial lubricant drops. J Ophthalmol 2016;2016:
1342056.
17. Salouti R, Nowroozzadeh MH, Zamani M, Ghoreyshi M,
Salouti R. Comparison of the ultrasonographic method
with 2 partial coherence interferometry methods for intraoc-
ular lens power calculation. Optometry 2011;82(3):140–147.
18. Ishioka M, Kato N, Takano Y, Shimazaki J, Tsubota K. The
quantitative detection of blurring of vision after eyedrop
instillation using a functional visual acuity system. Acta
Ophthalmol 2009;87(5):574–575.
19. Ventura BV, Ventura MC, Wang L, Koch DD, Weikert MP.
Comparison of biometry and intraocular lens power calcula-
tion performed by a new optical biometry device and a refer-
ence biometer. J Cataract Refract Surg 2017;43(1):74–79.
JANUARY 2021